“do i need exercise?” a qualitative study on factors

The Qualitative Report The Qualitative Report

Volume 24 Number 5 Article 10

5-18-2019

“Do I need exercise?” A Qualitative Study on Factors Affecting “Do I need exercise?” A Qualitative Study on Factors Affecting

Leisure-Time Physical Activity in India Leisure-Time Physical Activity in India

Shalini Garg SCTIMST, [email protected]

V Raman Kutty SCTIMST, [email protected]

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Recommended APA Citation Recommended APA Citation Garg, S., & Kutty, V. R. (2019). “Do I need exercise?” A Qualitative Study on Factors Affecting Leisure-Time Physical Activity in India. The Qualitative Report, 24(5), 1065-1082. https://doi.org/10.46743/2160-3715/2019.3883

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“Do I need exercise?” A Qualitative Study on Factors Affecting Leisure-Time “Do I need exercise?” A Qualitative Study on Factors Affecting Leisure-Time Physical Activity in India Physical Activity in India

Abstract Abstract Physical activity can reduce the risk of premature mortality from various chronic diseases. Previous research in Kerala, India indicates several barriers which can impact physical activity levels. Perceptions about the importance of health-promoting physical activity were examined among adults in Kerala and various facilitators, motivators and barriers to physical activity were identified using focus group discussions and interviews with key informants. At present, the attitude of people and health professionals is that physical activity has to be taken up when diagnosed with a disease (obesity, diabetes) and advised by a health professional. Men were more likely to start exercising after being advised by a health worker compared to women who were restricted by family roles and gender norms. Hence, there is an urgent need to include physical activity in all health communications to increase awareness about the role of physical activity in health promotion and disease prevention.

Keywords Keywords Physical Activity, Inactivity, Qualitative, Low and Middle Income Country, LMIC

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Acknowledgements Acknowledgements We would like to thank all the people who agreed to participate in the interviews and shared their views with us. We want to thank Harsh for assisting in translating and recording during the focus group discussions and Rupesh for facilitating contact with the gatekeepers.

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The Qualitative Report 2019 Volume 24, Number 5, Article 4, 1065-1082

“Do I need exercise?” A Qualitative Study on Factors Affecting

Leisure-Time Physical Activity in India

Shalini Garg and V Raman Kutty Sree Chitra Tirunal Instutute for Medical Science and Technology (SCTIMST), Trivandrum,

India

Physical activity can reduce the risk of premature mortality from various

chronic diseases. Previous research in Kerala, India indicates several

barriers which can impact physical activity levels. Perceptions about the

importance of health-promoting physical activity were examined among adults

in Kerala and various facilitators, motivators and barriers to physical activity

were identified using focus group discussions and interviews with key

informants. At present, the attitude of people and health professionals is that

physical activity has to be taken up when diagnosed with a disease (obesity,

diabetes) and advised by a health professional. Men were more likely to start

exercising after being advised by a health worker compared to women who

were restricted by family roles and gender norms. Hence, there is an urgent

need to include physical activity in all health communications to increase

awareness about the role of physical activity in health promotion and disease

prevention. Keywords: Physical Activity, Inactivity, Qualitative, Low and

Middle Income Country, LMIC

Physical activity can reduce the risk of premature mortality from various chronic

diseases like diabetes and cardiovascular diseases in addition to contributing to a number of

other health benefits (Lee et al., 2012; Warburton, Nicol, & Bredin, 2006). Despite the known

benefits of physical activity, very few people, especially in low income countries, are found

to engage in regular physical activity for health benefits. Evidence on physical activity

practices in these countries is scarce.

The state of Kerala is witnessing demographic and epidemiological transition, with

the largest proportion of older adults and those suffering from non-communicable diseases

(NCDs). It shares almost 75% of total disease burden from NCDs (ICMR, PHFI, & IHME,

2017) of the country burden from NCDs. Kerala also had the highest number (19%) of people

living with diabetes in the country in 2016 which is higher than the country average of 12%

(AMCHSS Research Team, 2018).

Previous research in Kerala indicates several barriers which can impact physical

activity levels. Women associated physical activity mostly with household activities and most

of them considered their activity levels adequate. (Mathews, Lakshmi, Sundari Ravindran,

Pratt, & Thankappan, 2016) Commonly reported barriers were lack of time, motivation, and

interest; stray dogs; narrow roads; and not being used to the culture of walking. Facilitators of

activity were seeing others walking, walking in pairs, and pleasant walking routes

(Daivadanam et al., 2013; Mathews et al., 2016). There is currently little evidence of

successful physical activity interventions in low income countries. Given the low levels of

exercise and the associated structural and other barriers, promoting physical activity in these

populations is likely to be complex. Although these studies have investigated barriers, no

studies have explored in-depth what people understand about the importance and role of

physical activity, what motivates them and how they overcome these barriers to participate in

physical activity, which is important in the development of strategies to promote physical

1066 The Qualitative Report 2019

activity. These studies were limited to women populations and reported fairly well

documented barriers and facilitators that have been reported from other parts of the world. A

number of interventions developed on stated barriers and facilitators have resulted in modest

and short-term effects. The need to understand the complex nature of cultural and local

perceptions regarding physical activity and how people understand its role in controlling or

preventing chronic diseases could provide more insights into the issue.

Given the rapid demographic transition and urbanisation, Kerala is an ideal setting to

study the risk factors of non-communicable diseases (Daivadanam et al., 2013). It makes

sense that any strategies evolved for promoting physical activity in this population might

have implication for rest of the country

Hence, this study examines the perceptions of adults in Kerala of the importance of

health promoting physical activity and identifies various facilitators, motivators and barriers

to physical activity. This study is a part of a larger study which looks into the determinants of

physical activity in Kottayam district of Kerala.

The authors of this study SG and VKR are public health professionals. SG (a migrant

to the state of Kerala for eight years) witnesses a slow decline in the physical activity levels

of her family. Looking around, she hardly finds children playing in the neighbourhood, let

alone adults doing leisurely physical time; puzzled by the situation, after weighing so many

factors like climate and accessibility, the problem is still looking her in the eye. She decided

to explore the question in her doctoral studies. VRK is her supervisor. VRK is a well-known

epidemiologist; although not a sports enthusiast, he maintains a consistent lifestyle with 45

minutes of vigorous physical activity every day. He has done a lot of research in the area of

chronic diseases, but the question still puzzles him: even after having almost 100% literacy

and development induced, like developed countries, why are the people of Kerala witnessing

a heavy burden of chronic diseases?

Methods

We carried out a qualitative study to gather in-depth comprehend the values

associated with physical activity in the daily lives of an average Malayali adult. The aim was

to explore the social and cultural norms around the concept of physical activity. The need for

exploration of normative behaviour made us use the focused groups for creating a discussion

among various viewpoints of the community. Physical activity is a non sensitive subject and

could be debated openly so focus group discussions were chosen as the primary source of

data collection (Creswell, 2013; Krueger, & Casey, 2009).

We undertook a qualitative study employing insights from various theories of health

promotion and socio-ecological theories (Bandura, 1999; Bronfenbrenner, 1993; McLeroy,

Bibeau, Steckler, & Glanz, 1988; Stokols, 1992). We used maximum variation sampling to

increase the likelihood of different perspectives and views within focus groups. Interviews

with key informants like fitness instructors and frontline workers supplemented the

information gained from these focus group discussions. A total of 28 adults participated in

four focus group discussions in addition to three key informants. These were conducted

between April-May 2018 in Kottayam district. The groups were carefully selected to

represent views of active as well as inactive people and represented both sexes and all

socioeconomic backgrounds (see Table 1 for composition of focus groups and key

informants). We asked them about the importance of exercise or physical activity in their

lives and various facilitators, motivators, and barriers to physical activity.

Shalini Garg & V Raman Kutty 1067

Sampling

A total of 28 participants were recruited into the study. The purposeful sample

included men and women between 18 and 65 years of age who were healthy enough to

perform moderate amount of physical activity, not having any physical, mental, or hearing or

speech deficiencies. The relatively broader age band was chosen to match the age distribution

in the state of Kerala which has an ageing population. The primary investigator was an

outsider to the setting (perceived as a north Indian, not fluent in the local language, slim and

coming from a renowned medical institute, compared to the participants who were all native

Keralites), and this may have influenced data collection in terms of the information they were

comfortable sharing. An understanding developed between participants and the primary

investigator. The sample was restricted to men and women between 18-65 years of age,

allowing for diversity in experiences. This focus group would allow insight into ways where

there may be opportunities for physical activity interventions to address issues of increasing

chronic disease burden.

We sampled participants from the urban and rural centres of Kottayam district Since

the objective was to recruit a multifaceted and diverse sample; we recruited pre-existing or

natural groups like women and men exercising together, child care groups, and patients of

chronic diseases to reflect a range of gender, age, socioeconomic status, and occupational

backgrounds. This sampling was also done to ensure a mix of active versus non active

participants. We sampled people based on their participation in recreational physical activity

programme (e.g., walking groups, aerobic dancing, swimming, gym activities) to find

motivators and facilitators. Table 1 presents details of the focus group characteristics. We

used a purposive sampling strategy, merged with techniques of theoretical sampling. Our

sampling strategy ensured that our sample includes sufficient number of active versus non-

active participants. Two groups of men and women actively participating in a gym belonged

to middle to higher socioeconomic status. Other two groups were accessed from government

run facilities in low socioeconomic areas. Our sample was limited as we failed to recruit

uniformly on the basis of socioeconomic status. It was keeping in mind the dynamics that

people from different socioeconomic backgrounds in the same group sometimes causes the

loss of vital information due to social norms around these complex stratifications.

Membership

group

Characteristics Description of the group

Focus group1-M Men’s group

participating in a

recreational

physical activity

programme

Men’s group were mostly men in the age group of 30-45

who were suffering from either chronic disease like

obesity or diabetes or hypertension. They had joined the

programme after being advised by their doctors or family

members and gaining knowledge from social media. Most

of them had lived in western or gulf countries and had

past experience of sport or exercising in gymnasium.

Three of them were practising clinicians or surgeons. One

was a nurse. Others were employed in various marketing

and sales jobs. All the men were married and had

children. Only one of them was participating with his

kids. All men had participated in sports or body building

activities before marriage but after marriage physical

activity declined. They chose this facility as it was within

a short distance from their houses.

Focus group2-F Women’s group The women’s group mainly consisted of working women


participating in a

recreational

physical activity

programme

aged 30-45 years but one young girl was also a part of a

group. The members preferred a form of exercise which

was a heavy intensity dance cum exercise called the

zumba; only two women were working out on treadmill

and other gym equipment. The group instructor was also

leading the discussion where she was emphasising the

importance of health promoting exercise

Focus group3-W Community

members from low

socioeconomic

background.

Members of community mostly included women age30-

60 years, all of them had one or more person in their

families living or dead of a chronic disease. Cancer was a

common cause in almost 80% of the deaths. One person

was a patient of breast cancer. All of them were

homemakers and educated at least till class 10.None of

them were participating in any form of leisure time

physical activity. All were married and had children or

grandchildren

Focus group4-G Patients of NCD

clinic-

Patients suffering from one or more chronic diseases,

mostly diabetes and cardiovascular diseases. Mostly men.

All married and above the age of 40.They belonged to

different socioeconomic backgrounds.

Key informant1 Instructor Woman aged 30, working as Zumba instructor for the last

10 years in an outdoor facility

Key informant2 Instructor and

owner

Man aged 60, worked as fitness consultant in many

countries, currently owns business in this sector for last

two years

Key informant3 Health care worker Woman aged 55, working for last 15 years as community

health worker.

Table 1. Details of focus groups

Our sample also included key informants who brought in a variety of perspectives

from other stake holders (See Table 1). These people were selected from various sectors like

sports, health care, and community leaders. These were generally group leaders or

gatekeepers who gave a general overview of the need for such a facility or service. They also

gave insights into the barriers and road ahead for physical activity promotion.

Ethics Statement

Institutional Ethics committee of Sree Chitra Tirunal Institute for Medical Science

and Technology, Trivandrum, India granted the approval for the study. We provided

information sheets in English and Malayalam. At the beginning of the focus group,

participants were given opportunity to ask any questions, and it was explained to them that

participation was completely voluntary and they could withdraw at any time without giving

any reason. We gave written consent forms to all participants and made sure that the

participants realize the extent of their involvement in the study and that confidentiality and

anonymity with respect to the information shared shall be maintained.

Data Generation

We conducted all focus groups at the time and place of convenience for participants.

Usual meeting places like fitness centres, anganwadi (rural mother and childcare centres), and

waiting halls of clinics were chosen for group discussions. Some refreshments were given


during the interviews. We gave no financial compensations for participating in the study. All

focus groups were conducted in Malayalam. Interviews with key informants were conducted

in English and Malayalam. The focus group guides were prepared after reviewing previous

research in similar context and were modified to answer the specific research question

(Alvarado, Murphy, & Guell, 2015; Daniel & Wilbur, 2011; Mathews et al., 2016). An

iterative approach was used for data collection. (Creswell, 2013). We contacted, recruited and

visited the participants iteratively. Recruitment finished when the researchers agreed that

analytical saturation has been reached. Based on our study design, we intended to recruit up

to 25 participants. A small number of participants was chosen as it is easy to visit them

repetitively for more in-depth investigation of their experiences.

Data Handling and Analysis

The discussions were digitally recorded, transcribed and translated and analysed using

thematic analysis. We used both inductive and deductive coding. We applied “axial coding”

process to connect code categories; this helped in identifying common themes. Constant

comparing and contrasting method helped in sorting of similarities and differences in the data

and allowed interpretation of themes within and across groups (Creswell, 2013). Both

researchers in the study belong to public health discipline and their background could have

influenced the interpretation of results. Both are physically active and very interested in the

promotion of physical activity which could have affected the research process. However, the

themes were discussed among the authors and a reflexive stance was taken to minimise bias.

For example, on one occasion, inadequate advice by medical professionals (VRK is a medical

doctor) was found to be a factor for inadequate physical activity among chronic disease

patients, but the authors retained the theme and consequently this emerged as a major finding

of the study. The primary investigator completed all the data analysis tasks with regular

discussion with the co-researcher.

Results

A selection of quotes is used in the paper to illustrate the themes. Box 1 summarises

the main themes emerging from the analysis.

The Most Common Forms of Exercise

Most of the participants talked about walking as a preferred form of exercise as it was

acceptable in their society, not expensive, and could be done anywhere; although a

companion would be necessary for safety from stray animals during walking. It was also

appropriate for older age as compared to swimming or running. Women living in rural areas

and belonging to lower socioeconomic background and people of older age were more likely

to participate in walking as a health enhancing physical activity.

Women thought that taking care of the household and small children was in itself a

full-time activity. W2: I think this is enough for us, we are old, and these kids make us run all

day. Do you think we need more exercise?

Men talked about sports as their favourite form of physical activity. They liked

organised activity like swimming, cycling, badminton, or football. Men seemed to be

concerned about time and fear of injuries while doing vigorous forms of activity like hiking

and trekking (which they enjoyed in their youth).


M1: What do you think is the best form of exercise, I have seen people abroad,

they hike and trek.

M3: I have joint problems, swimming is the best exercise for people like me,

and also if we start doing these things now, we might fall or something and

then we won’t do anything ever.

Women talked about going to the gym and using indoor gym equipment as something

prohibited for them. They preferred yoga and 1070 Zumba dance as more subtle and feminine

forms of exercise compared to pushing weights. Very few took to treadmill and other gym

equipment.

F1: My mother was very shy to take up gym exercises, but I pushed her into it.

I know it’s much better if you really want to lose weight. I have been living in

(mega city) my whole life, so it’s okay for me but people here find it hard to

see women pushing weights.

Main Motivators

Participants talked about health benefits like mental, physical and, social; however,

diagnosis of disease and doctors’ advice were main motivators for them to join a physical

activity programme. Past experience and passion for sport and upcoming of a new facility

which is accessible and affordable were other factors.

M4: It’s a good source of social interaction. I love making new friends. I am

passionate about swimming since my childhood and so my kids have taken

after me.

M6: I have lost 30 kilos of weight in last 3 years, which is an ongoing

motivation for me.

M7: I have hypertension for last 3 years and doctors have advised me lifestyle

modification. Also these blogs and social media messages motivate me to stay

healthy.

Many men appeared to do activities with their children when they came to a supervised

facility; however, women were not so keen on coming with their children. They said they

joined the group as they returned from work.

Perceived Barriers

Low awareness about health benefits of exercise, people spending too much time on

electronic gadgets (screen time), and attitude (laziness, need of exercise meant only for

people with obesity) were considered barriers for participating in recreational physical

activity. Participants agreed on time, role, and responsibilities as major barriers to exercise.

Few participants thought that their work or household activities were enough physical work

for them.

W1: We have small children, where is the time to go for other activity? Isn’t

this enough?


Many members did not know the exact importance of exercising. Some also talked about

whether prohibiting walking or playing outside on most days. Safety was another issue for

some people. Lack of skills was also a barrier for participants.

W5: Why me? I don’t have any diseases or anything; I don’t need exercise.

W3: I think we should walk everyday with arms swinging and lightly for ten

minutes.

Women talked about their husband’s attitude, fear of injuries, and consequent loss of

work as barriers to physical activity.

There was also a lack of attitude among members as they said that exercise is only for

others not for them. They also talked about having time and energy but still being lazy and

forgetful.

W3: We will die anyway, so let’s eat and enjoy. What’s so much ado about,

my husband says—he is a diabetic. We are also lazy and forgetful after getting

old.

Affordability of Recreational Physical Activity

Participants consented upon the fact that the middle class population cannot afford the

cost of exercise facilities. Participants who had lived in western countries discussed the lack

of culture of saving for recreation activities. Most of the women were spending on such

activities now as it was really important for them to care for their health now than later. They

suggested cost has to come down for most of the middle class to be able to use these

facilities. Women suggested that yoga in nearby anganwadi or local clubs could increase

participation and awareness.

One key informant who ran outdoor activities also talked about the cost of keeping the

business alive while keeping the cost low for increasing membership among middle class

women and students. He also spoke about building an indoor sport facility for adolescents

only if his present business thrives. He discussed the culture of allocation of resources in

household.

M4: In western societies there is a trend for investing and spending on

recreational activities just like we save for gold.

K1: I have worked in various places. It’s difficult to sustain a business like

this. I want to build a franchise of this fitness chain in Kerala. People have

start accepting this; fitness culture has been here but very limited to young

men and upper class. I want to take it to everybody. There has to be a dramatic

shift in thinking culture, it’s happening slowly. . . . There is a stark difference

in money spending habits of women and men here . . . where people spend so

much money each month on recharging mobile and cable connections but are

not aware of the benefits to health by investing the same money in physical

activity. . . . I use my trainers to run community programmes in low

socioeconomic groups. They are the ones who are hit the hardest and thus left

with unhealthy lifestyles.


Body Image

A main factor for women to start exercising was dissatisfaction with their body image

(Laus, Costa, & Almeida, 2011; Pruis & Janowsky, 2010). Most working women felt that

positive body appearance improved their confidence and self-esteem at work place. For

younger women, it was important for them to reduce weight to avoid future difficulties in

finding a match for marriage and avoid embarrassment at social and family gatherings.

Although they understood the importance of health benefits of exercise like improving

efficiency of daily activities, body image was a very strong motivation to exercise. One key

informant who was an instructor in an outdoor facility kept stressing the importance of

lifelong health promoting physical activity. However, the participants were candid about their

body image and self-esteem as main motivators for joining the gym.

F1: My wedding is three months away; I want to look good for my marriage.

Moreover, those meds for weight loss are not healthy. . . . As the saying goes,

“No pain, no gain.”

F6: I want to look younger than my husband; everyone tells me I look older

than him.

F7: I have been told to reduce weight as I don’t look good in my dresses, and

my family feels ashamed when guests come over. (11 year old girl on her

appearance)

Social, Cultural, and Gender Norms

These were important especially for women participants. Although men were not

averse to the idea of exercising, they thought exercising is a western concept and habitual

physical activity should be enough for body health.

Women talked about the traditional roles of women in labour intensive household

work and extensive walking for fodder and collecting water and firewood. Lately, all these

activities have become mechanised and lives have grown more sedentary. Women believed

that family responsibilities are her primary concern, and she herself considers her health

secondary to kids and family. Society does not appreciate women who go out for exercise and

waste time and money for such luxury. Walking has become acceptable now, however, they

require someone to accompany them for safety purposes. Some women go to exercise

without informing their families. There is a lot of social pressure on women on how to live

and behave. In order to avoid the humiliation and public shaming, women sit at home and

watch television rather than go out with kids and play. Schools train sport teams but there are

no concerted efforts to improve the physical fitness of students in schools. Women suggested

including lifestyle education in school so that girls are aware of their lifestyle choices right

from the beginning—not when it’s very hard for them to change.

Some women believed that such leisure activities are an upper class thing and not for

all. Lower social class worked hard as it is a necessity for them; however, middle class

neither has money to afford health promoting activities nor is involved in manual labour.

F6: We have to get kids ready for school, pack lunch boxes, get hot water

ready for the man to take bath; men are taking their walk at this time.

F5: Society scares us, we want freedom.

F4: We can’t tell people we are going to a gym to exercise; there will be a lot

of talk about it.


W4: Our primary duties are home and family. Where is the time and energy

after that?

K2: Schools are supposed to inculcate healthy habits right from the beginning;

they should teach lifestyle choices just like they teach traffic rules and

environment saving. I guess this is a priority now.

Attitude

Some of the comments regarding reasons for not exercising were: laziness, not having

time, and no need for exercise.

W7: Exercise is meant for overweight or others; it’s not for me.

W3: We’ll die eventually—what is the point of exercising?

G4: Medicines will cure us; we don’t need exercise.

Awareness about Physical Activity and Chronic Diseases

There seemed to be low awareness about health benefits of physical activity. People

were aware about chronic diseases as almost all members were either living with a disease or

had a living or dead family member with chronic disease, but physical activity figured rarely

in their accounts. The main emphasis was on diet and pollution. People had conflicting ideas

about risk factors of disease: heredity, behaviour, psychological, and social. There seemed to

be misconceptions regarding causes of disease like migration and drinking sugary juices.

Assumptions like need for exercise only after a diagnosis and advice by a health professional

were also frequent. Women believed that household activities were enough to take care of

their daily physical activity requirements as childcare demands too much energy and also

because they don’t need to reduce weight. People believed disease makes them tired and

exhausted, so they are left with no energy to exercise and they should rest more. Moreover, in

old age people are supposed to rest.

G1: I have been an avid sportsman and a body builder my whole life, but now

I don’t feel the energy after all the diet control.

W9: Physical activity helps in diabetes, but I am not sure about other diseases.

W8: My father has diabetes and blood pressure. I didn’t know I have a risk

too.

W1: Earlier there was no treatment; people were scared of chronic disease, but

now treatment is easily available, so nobody worried.

A participant who is a surgeon by profession lamented upon the fact that even after doctor’s

advice, few people went out for exercising.

G1: Health professionals advise more medicines. Every time I go, they change

medicine; now I am trying (alternative medicine).

There were conflicting ideas about causes of diseases like:

G1: Migration causes change in lifestyle, but when I came back home, there

was no work, and so I think I got all these problems.

G6: I drank a lot of sugary juices after my surgery, and so I got this disease.


There was more emphasis on diet restriction like salt and fatty foods.

M6: I have turned to vegetarian diet now. These food habits are the real

problems; you should watch the lectures of Prof (a renowned oncologist).

W5: All diseases can be cured by dieting. All this pollution and pesticides are

causing the disease. . . . Government should do something about all this plastic

and pesticides.

Health Communication: Professional and Mass Media

Most health professionals described medicines as the main pillar of treatment. Doctors

themselves perceived various barriers like time and attitude for giving advice on lifestyle

modification. There was no awareness about how to prevent diseases in the first place.

Doctors’ advice about exercise was almost always insufficient with respect to time and

intensity. They were also not referring the patient to an expert for consultation.

G3: My doc asked me to walk for 5-10 minutes every day slowly. I am old and

also could hurt myself.

G4: My doc asked me to start exercising but nothing else.

M5: I asked my doc whether I could exercise; he said if you can, you should.

K2: There is no physical education in our school; they only ask children who

are fat to reduce their weight.

Health communication in schools was limited to reduction of weight. Television programmes

dedicated to certain diseases emphasised exercising, but only in few cases, and so people

believed exercise is only for people with certain diseases. Health communication mainly

emphasised diet control and soil and water pollution as main contributors to disease.

W3: I have never seen any physical activity promotion on TV. I have read

sometimes in magazines, but it is only for people with obesity. . . .

People suggested that health communication should be done in a friendlier and acceptable

manner, to include role models and communicate in everyday comprehensible ways as in the

case of immunisation.

K3: Yes, I think if physical activity is also promoted like immunisation as a

preventive measure, roping in celebrities, people will pay attention.

Discussion

Although it has been well over 50 years since the first study by Jeremy Morris

examining association of physical activity with cardio vascular diseases (Morris & Crawford,

1958), reasons why most people are still inactive in their daily lives is a mystery (Bauman et

al., 2012). Only recently has physical activity research started looking up in low and middle

income countries. Very few studies have tried to explore the factors affecting physical

activity in these culturally complex societies. This study was undertaken to contextualise the

factors which lead to widespread physical inactivity in a small population in India.


Summary of Principal Findings

We found that adults living in Kottayam had low awareness about health benefits of

physical activity. Awareness about causes of chronic diseases was low. This may be due to

low emphasis given to physical activity during health communication: physicians, health

workers, and media. Main motivations to participate in physical activity were perceived

health benefits, enjoyment, and positive body image. Body image was the principal motivator

for physical activity among women. All participants were married except one young girl, so

it’s difficult to differentiate between the changes in motivations during the two phases of life.

Most of the active men belonged to socioeconomically upper backgrounds and had been

diagnosed with a chronic disease. Most men admitted being physically active during their

youth and slowly slipping into a sedentary life style after marriage due to change in priorities.

In contrast, women had no past experience of recreational physical activity (except classical

dance forms) and were taking up physical activity to improve body image and self-esteem.

Social restrictions in the form of family and gender norms were a major barrier for women.

They asserted that upper class could afford preventive and treatment services, but for middle

class it was important to invest in preventive care (i.e., people should make conscious efforts

to invest some finances in health promoting measures). Time as a barrier needs to be explored

in future studies as people tend to forget the amount of time spent in front of the screen (e.g.,

watching sports, social media, virtual games, watching other kinds of visual media) which

could be effectively used for community sports or family leisure time physical activity. It also

needs to be examined whether this time consumption varies by age, sex, and socioeconomic

background. Also, time spent in travelling to and from workplaces is a major concern for

people citing time as a major barrier. For women, established gender roles as primary care

givers (packing lunch for kids and family in the morning and evening, prioritising family’s

health over their own) deprived them of the opportunity of walking (while men could very

well take their health walk or sleep during that time). The only time women could enjoy was

summer vacations when children were not leaving for school early morning. Cultural norms

associated with disease like taking rest rather than exercising may hinder uptake of physical

activity by people living with chronic disease especially older groups. Further, the role of a

physician as a prescriber of pills also hinders health workers from encouraging physical

activity among patients.

There was an overall underestimation of the importance of recreational physical

activity for otherwise healthy individuals among all communities. While some of the

motivators like body image and enjoyment were similar to general populations elsewhere in

the world, it differed by age and marital status in this study (Alvarado et al., 2015;

Caperchione, Chau, Walker, Mummery, & Jennings, 2015). Diagnosis of disease and advice

by a physician were major motivators which meant that there is a need for increasing

awareness among masses and health professionals about the adequacy of physical activity in

primary as well as secondary prevention. This could be a challenge as health professionals

are trained and oriented more for treatment rather than preventive care (Banu et al., 2014;

Morrato, Hill, Wyatt, Ghushchyan, & Sullivan, 2006; Peek, Tang, Alexander, & Chin, 2008).

Some of the barriers identified like roles and responsibilities, attitude, lack of social support,

and cost of recreational facilities is also similar to the findings in studies done in other

populations (Alvarado et al., 2015; Daniel & Wilbur, 2011; Jepson et al., 2012; Thankappan,

Mathews, Pratt, & Jissa, 2015). Time, laziness, and perception of household activities as

replacement for health promoting physical activity should be recognized as attitudinal issues.

Change in roles and responsibilities also needs to be understood in light of changing priorities

with each stage of life (Mathews et al., 2016). The barriers we identified also meant that it

was difficult for people to exercise with their families. There was also a finding about the


economies associated with physical inactivity among women where they prioritised their

children’s participation in a range of physical activities.

Built environment was a major factor as most of the facilities like parks and

playgrounds are not accessible or are not well managed. There is hardly any space for

footpaths in Kerala, much of which is encroached by vehicle parking. Rain, traffic, and stray

dogs are leading people to walk early in the morning and with a companion. This finding

echoes with the latest trends in physical activity research. Activity enabling environments are

the latest approach to intervene for widespread and long lasting effects (Bosdriesz, Witvliet,

Visscher, & Kunst, 2012; Sallis et al., 2016).

Strengths and Limitations of the Study

Groups were selected from a range of backgrounds to bring diversity and maintain

variation in the perspectives which brought rich description and detailed views from all

sections of society. Although studies have reported facilitators and barriers to physical

activity in high income and middle income populations, we tried to provide a balanced and

nuanced depiction of the social and cultural complexities that play a major role in making

lifestyle choices in countries like India. Where data allowed, we also looked at variations due

to age, gender, socioeconomic status, and area of residence. We tried to differentiate factors

which were common with other country populations and factors which were specific to study

population. Almost all participants were married and middle aged (above 30 years), which

could limit the generalisability of findings to other groups. Also, the views about motivations

at younger age levels (18-30 years) could not be assessed in depth.

Since gatekeepers were used to recruit, it is not possible to give details of the people

who were approached and who declined. Focus groups were undertaken in places and

languages that participants were comfortable with. This facilitated open and relaxed

discussions. Purposive sampling of participants who were active and inactive proved

effective in achieving saturation of key themes. Since the study was limited to only one

district and number of focus groups was only four, it is difficult to ascertain the broader

generalisability of our findings. However, we believe that the depth of enquiry has generated

insights that are expected to be largely transferable to populations living in other parts of

Kerala and India.

Implications for Policy Practice and Research

The promotion of a physically active lifestyle as an affordable and effective means to

prevent and treat chronic disease and to improve quality of life and well-being should be a

priority for government agencies, policy makers, and health professionals—especially in low

resourced settings which are hardly in a position to take the burden of chronic diseases.

Strategies for encouraging physical activity among adults in Kerala need to recognise

that, at present, the attitude of people and health professionals is that physical activity has to

be up taken after a certain stage in their lives such as when diagnosed with a disease and

advised by a health professional. So the strategy should emphasise health care professional

knowledge and motivate them for opportunistic counselling regarding physical activity to all

patients regardless of age and sex (Armit et al., 2009; Kirk, 2003; Morrison, Shubina, &

Turchin, 2012; Sallis et al., 2015).

Policy measures should ensure education about physical activity right from the

childhood. It would help if settings like school, workplace, and community gatherings are

used to create awareness and follow up with various physical activity interventions. Many

barriers like weather (it rains six months in a year) and hilly terrain makes outdoor activities


like walking trails and jogging parks impractical. Built environment (i.e., the environment

that is created for people to live in: cities, transport, workplaces, schools) is not conducive to

an active lifestyle and requires policy measures using intersectoral cooperation. We need

more scientific evidence to guide policy and practice if we want to change the economic,

physical, and social factors that influence our behaviour (Kohl et al., 2012). The motivations

we have identified in this study need to be considered in line with the barriers in order to

build up successful interventions. Also the contexts of lives (places and ways in which people

spend their leisure time or spend their money) have to be considered to effectively implement

such interventions.

Conclusions and Recommendations

Adults in Kerala are substantially less physically active which contributes to high

levels of diabetes and other chronic diseases in the state (Thankappan, Mathews, Pratt, &

Jissa, 2015). Our study indicates that there is an urgent need to include physical activity in all

health communications. Strategies should aim at increasing awareness and health

communication for health promoting physical activity in addition to policy measures to

improve activity enabling environments.

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Appendix

FOCUS GROUP GUIDE: WOMEN’S GROUP

Participants of a physical activity programme (i.e., gymnasium)

Selection criteria: Female,18-65 years of age, participating in gym programme for at least a

month

Copies of informed consent forms should be provided to each participant and read aloud for

the benefit of those who cannot read. Participants should be provided an opportunity to ask

any questions. Try to ask all the questions below in the order given, but it is more important

to maintain the flow of discussion. Suggested probes have been included. You should try to

encourage participation of all group members in the conversation. Start by explaining the

ground rules as follows: Before we start, I would like to remind you that there are no right or

wrong answers in this discussion. We are interested in knowing what each of you think, so

please feel free to be frank and to share your point of view, regardless of whether you agree

or disagree with what you hear. It is very important that we hear all your opinions. You

https://doi.org/10.2337/dc11-1635

https://doi.org/10.1007/s11606-008-0737-3

https://doi.org/10.1080/00221309.2010.484446

https://doi.org/10.1016/S0140-6736(15)01284-2

https://doi.org/10.1016/j.pcad.2014.10.003

https://doi.org/10.4103/0019-557X.157535

https://doi.org/10.4103/0019-557X.157535

https://doi.org/10.1503/cmaj.051351


probably prefer that your comments not be repeated to people outside of this group. Let's start

by going around the circle and having each person introduce herself. (Members of the

research team should also introduce themselves and describe each of their roles.)

1. What do you think about the topic that has brought us here today (physical activity)?

2. According to you what is the most important reason for you to join the gym.

3. According to you what are the reasons for

Doing exercise?

Not doing exercise?

4. According to you what are the needs and services required to make more people

exercise as you do? (child support, moral support, social norms, role models)

5. Do you have any past experience of sport or physical activity participation?

6. What is your source of information about physical activity? (health professional,

media, children, relatives’ other networks)

7. Let’s summarize some of the key points from our discussion. Is there anything else?

8. Do you have any questions?

Thank you for taking the time to talk to us!!

FOCUS GROUP GUIDE: MEN’S GROUP

Selection criteria: men, aged 18-65, who participate in gym programme for over a month.











by going around the circle and having each person introduce himself. (Members of the



2. According to you what is the most important reason for you to join the gym.


Doing exercise?

Not doing exercise?


exercise as you do? (Child support, moral support, social norms, role models)



media, children, relatives other networks)

7. Do you think of continuing this participation for another six months? Why?

8. What do you think about women doing exercise in your community?





FOCUS GROUP GUIDE: NCD clinic patients

Selection criteria: Patients 18-65 years of age, diagnosed with any of the chronic diseases

and attending NCD clinic at least for the second time.








please feel free to share your point of view, regardless of whether you agree or disagree with

what you hear. It is very important that we hear all your opinions. You probably prefer that

your comments not be repeated to people outside of this group. today. Let's start by going

around the circle and having each person introduce herself. (Members of the research team

should also introduce themselves and describe each of their roles.)


2. According to you what is the most important reason for people doing exercise.

3. Do you exercise?


Doing exercise?

Not doing exercise?


exercise? (child support, moral support, social norms, role models)


7. Has any health professional advised you to increase your physical activity? If yes,

what are the things that were told?

8. How many times were you asked about your physical activity? (number of visits,

initial or many).

9. Do you think that advice form a health professional had a role in improving your

physical activity?




FOCUS GROUP GUIDE: MIXED GROUP

Selection criteria: 18-65 years of age, men/women, healthy enough to exercise.












by going around the circle and having each person introduce herself. (Members of the



2. According to you what is the most important reason for people to participate in

physical activity?


Doing exercise?

Not doing exercise?


exercise as you do? (child support, moral support, social norms, role models)



media, children, relatives other networks

7. What kind of physical activity is most valued in your community?




Author Note

Shalini Garg is a senior doctoral fellow at the Achutha Menon Centre for Health

Science Studies, Sree Chitra Tirunal Institute for Medical Science and Technology,

Trivandrum, India. Correspondence regarding this article can be addressed directly to: Shalini

Garg, AMCHSS, III floor, SCTIMST, Trivandrum, India, 650119; E-mail:

[email protected].

V Raman Kutty is the Head and Senior Professor at the Achutha Menon Centre for

Health Science Studies, SCTIMST, Trivandrum, India.

We would like to thank all the people who agreed to participate in the interviews and

shared their views with us. We want to thank Harsh for assisting in translating and recording

during the focus group discussions and Rupesh for facilitating contact with the gate keepers.

Author contributions: Conceived and designed the study, performed the study,

analysed the data, wrote the paper: SG; critically supervised, manuscript layout, reviewed:

VRK Supporting

Copyright 2019: Shalini Garg, V Raman Kutty, and Nova Southeastern University.

Article Citation

Garg, S., & Kutty, V. R. (2019). “Do I need exercise?” A qualitative study on factors

affecting leisure-time physical activity in India. The Qualitative Report, 24(5), 1065-

1082. Retrieved from https://nsuworks.nova.edu/tqr/vol24/iss5/10

mailto:[email protected]

“do i need exercise?” a qualitative study on factors

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